the puerperium

Fourth stage

Obstetrics
Lec-1
Dr.Wildan

4/10/2015

The puerperium (Part 1 )
The puerperium refers to the 6 week period following childbirth when considerable adjustments occur before return to the pre-pregnant state. (By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the non pregnant state).
During this period of physiological change, the mother is also vulnerable to psychological disturbances, which may be aggravated by adverse social circumstances.
Physiological changes
1-Uterine involution
Involution is the process by which the postpartum uterus, weighing about 1kg, returns to its pre-pregnancy state of less than 100g.
Immediately after delivery, the uterine fundus about 4cm below the umbilicus.
Within 2 weeks, the uterus can no longer be palpable above the symphysis.
By 6 weeks postpartum, the uterus has returned to its normal size.
Involution occur by process of autolysis.
Involution appears to be accelerated by the release of oxytocin in women who are breast feeding.
The height of uterine fundus is measured daily to ascertain the trend in involution.
Causes of delayed involution:
Full bladder.
Loaded rectum.
Uterine infection.
Retained process of conception.
Fibroids.
Broad ligament haematoma.
A delay in involution in absence of any other signs or symptoms, e.g. bleeding is of no clinical significance.


2-Genital tract changes
The cervix:
In the first few days, the cervix can readily admit two fingers.
By the end of the first week it should become increasingly difficult to pass more than one finger.
By the end of second week the internal os should be closed. However the external os can remain open permanently, giving the characteristic appearance to the parous cervix.
The vagina:
In the first few days, the stretched vagina is smooth and oedematous, but by the third week rugae begin to reappear.

3- Lochia

Lochia is the blood stained uterine discharge that is comprised of blood and necrotic decidua.
Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable.
The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba). The period of time the lochia can last varies, although it averages approximately 5 weeks.
Offensive lochia, which may be accompanied by pyrexia and a tender uterus, suggest infection and should be treated by broad spectrum antibiotic.

4- Abdominal wall

The abdominal wall remains soft and poorly toned for many weeks. The return to a pre pregnant state depends greatly on maternal exercise.

Routine observations

During the patient’s stay in hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void.
The perineum should be inspected daily if there has been any trauma and the episiotomy or other wounds checked for sign of infection.
Observations should also include breast examination and examination of the leg.
Women are encouraged to ambulate and to eat a regular diet.
It is traditional to check haemoglobin level on day 3 unless otherwise indicated. And most women who are particularly symptomatic should be transfused if their haemoglobin level at this time is <8g/dl.


Ambulation in the puerperium
It is now well established that early mobilization after childbirth is extremely important (as soon as possible)
Limb exercise will be particularly important to encourage venous flow in the leg veins of any mother who has been immobilized in bed for any reason.
Exercise to the abdominal and pelvic floor muscles are most valuable in restoring normal tone which may have been lost during pregnancy.

Complications of the puerperium

The most serious complications are
thromboembolism,
infection
haemorrhage
mental disorders
breast problems
Other problems include
perineal discomfort
disturbance of bladder and bowel function
obstetric palsy
symphysis pubis diastesis

"Perineal complications"

Discomfort is greatest in women who sustain spontaneous tear or have an episiotomy, but especially following instrumental delivery.
Treatment:
local cooling (with crushed ice, or tap water).
Topical anaesthetics such as 5%lignocain gel.
Analgesic as paracetamol or diclofenac suppositories.
Codeine derivative are not preferable as they have tendency to cause constipation.
Infections of the perineum are generally uncommon considering the risk of bacterial contamination during delivery.
Management:
Swab for microbiological culture from the infected perineum.
Broad spectrum antibiotic.
If there is collection of pus, drainage should be encouraged by removal of any skin sutures; otherwise infection would spread, with increasing morbidity and poor anatomical result.


"Bladder function"
Voiding difficulty and over-distension of the bladder are not uncommon after childbirth, especially if regional anasthesia has been used.
Women who have undergone traumatic delivery such as a difficult instrumental delivery, or who have suffered multiple/extended lacerations or a vulvovaginal haematoma, may find it difficult to void because of pain or periurethral oedema.
Fistulae: pressure necrosis of the bladder or urethra may occur following prolonged obstructed labour, and incontinence usually occurs in the second week when the slough seperates.

"Bowel function"

Constipation is a common problem in the puerperium. This may be due to:
An interruption in the normal diet.
Possible dehydration during labour (so advice on adequate fluid intake and increase in fibre intake may be all that is necessary).
Constipation may also be the result of fear of evacuation due to pain from a sutured perineum, prolapsed haemorrhoids or anal fissures.
Anal incontinence and faecal urgency may occur following childbirth due to trauma to anal sphincter (either occult trauma or associated with a third or fourth degree tear).
Anovaginal /rectovaginal fistulae may occur. It is therefore important to consider a fistula as a cause of anal incontinence in the postpartum period.

"Obstetric palsy"

Obstetric palsy Is a condition in which one or both lower limbs may develop signs of a motor and/or sensory neuropathy following delivery.
Presenting features include sciatic pain, foot-drop, parasthesia, hyposthesia and muscle wasting.
Possible mechanisms:
Compression or stretching of the lumbosacral trunk as it crosses the sacroiliac joint during descent of the fetal head.
Herniation of lumbosacral discs (usually L4 or L5) can occur, particularly in the exaggerated lithotomy position and during instrumental delivery.

"Symphysis pubis diastesis"

Seperation of symphysis pubis can occur spontaneously in at least 1 in 800 vaginal deliveries.
It has been associated with:
Forceps delivery.
Rapid second stage of labour.
Severe abduction of the thigh during delivery.
Common signs and symptoms include:
Symphyseal pain aggravated by weight-bearing and walking.
Waddling gait.
Pubic tenderness and a palpable interpubic gap.
Treatment includes:
Bed rest.
Anti-inflammatory agents.
Physiotherapy.
Pelvic corset to provide support and stability.


"Secondary postpartum haemorrhage"
Definition: fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery.
The most common time is between days 7 &14
Aetiology:
Retained placental tissue (most common).
Endometritis.
Hormonal contraception.
Bleeding disorders, e.g. von Willebrand’s disease.
choriocarcinoma
In presence of retained placental tissue, suction evacuation of the uterus is the treatment of choice under antibiotic cover which is best started at least 12 h beforehand.
Great care must be taken at the time of curettage as the infected uterus is soft and easy to perforate.

"Thromboembolism"

The risk rises fivefold during pregnancy and the puerperium.
The majority of deaths occur in the puerperium (after the first week of the puerperium, hence after discharge from hospital) and are more common after caesarean section.

Puerperal Pyrexia

Is defined as a temperature of 38°C (104°F) or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours.
There are many causes of such a fever, but in the days prior to antibiotics it was a sign which was very much dreaded as it had a very poor prognosis. These days, with prompt recognition and treatment of the underlying cause, the outcome is considerably better.
Common sites associated with puerperal pyrexia include:
Chest.
Throat.
Breast.
Urinary tract.
Pelvic organs.
Caesarean or perineal wounds.
Legs.